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April 2013

Can A Combination Of ESWT And PRP Be Effective For Achilles Tendinopathy?

By Brian McCurdy, Senior Editor

Extracorporeal shockwave therapy (ESWT) has been a time-tested and effective treatment for Achilles tendinopathy. However, combining ESWT with platelet rich plasma (PRP) may be a particularly effective treatment, according to a new poster abstract that was recently presented at the American College of Foot and Ankle Surgeons (ACFAS) Annual Scientific Conference.

The abstract focused on 14 feet with Achilles tendinopathy that received ESWT alone and 14 feet that received both ESWT and PRP. One month after treatment, the abstract authors say patients who had both ESWT and PRP had an average decrease in the Visual Analogue Scale of 4.7 in comparison to a decrease of 2.9 in those who had only ESWT, a result the authors note is statistically significant. The study concludes that the combination of ESWT and PRP can provide quicker pain relief for patients with Achilles tendinopathy.

Abstract co-author Lowell Weil Jr., DPM, FACFAS, notes that ESWT has received more study than any other treatment for Achilles tendinopathy, the treatment is non-invasive and has “virtually no risk.

“People can return to life immediately without immobilization or missed work,” notes Dr. Weil. “Athletes can continue some training.”

Although PRP has received less study and shows mixed results, Dr. Weil says platelet rich plasma has never been shown to do any harm. He notes that an advantage of PRP is its noninvasiveness while a disadvantage is that the process is based on the host and the quality of the host’s healing properties.

“The major advantage of ESWT and PRP in comparison to other modalities is that ESWT and PRP both aim at repairing degenerative tendons whereas other modalities are geared to treat the inflammation associated with tendonitis,” says David Zuckerman, DPM. “ESWT and PRP both resolve degenerative tendinosis without surgical invention.”

Dr. Weil cites studies by Schon showing that ESWT potentiated the effects of PRP in an animal model. “Both have their specific effects on tissue and bone and both have shown benefits individually. They don’t act the same way so you are using a different mediated way to heal the tissue,” notes Dr. Weil, the President and Fellowship Director of the Weil Foot, Ankle and Orthopedic Institute.

As Dr. Zuckerman notes, PRP releases growth factors that recruit fibroblasts and macrophages, enabling the repair of collagen in the tendon structures. He says through cavitation, ESWT allows neovascularization of degenerative tendons. Therefore, PRP and ESWT both stimulate neovascularization and fibroblast production with the potential of increasing the effect of fibroblastic production and decreasing healing times, according to Dr. Zuckerman, the Director of ESWT Services at Excellence Shockwave Therapy in Woodstown, N.J.

Dr. Weil posits that the combination of ESWT and PRP might be effective in any tendinopathy or plantar fasciitis. In addition, Dr. Zuckerman says the combination of ESWT and PRP is in use for pseudarthrosis in the long bones of the lower extremity. He speculates that ESWT/PRP may also be useful for non-healing diabetic wounds and non-healing fractures.

According to the study, in addition to lateral ligamentous ankle pathology, peroneal tendon pathology and ankle joint pathology are commonly associated with unstable ankles. Study authors conclude that successful treatment for these three pathologies, which they have termed the “lateral ankle triad,” includes ankle arthroscopy, lateral ankle stabilization and peroneal tendon repair.

In this retrospective review, researchers evaluated the results of 302 patients who had ankle arthroscopy, lateral ankle stabilization and peroneal tendon repair. Study authors note that radiological imaging may not always allow the surgeon to identify the source of pathology effectively in an unstable ankle. Therefore, they recommend peroneal tendon inspection during lateral ankle stabilization and ankle arthroscopy to find intra-articular lesions that one may have missed preoperatively. As the study notes, the researchers observed that most peroneus brevis tendon tears were large, longitudinal tears against the posterior fibula, which is indicative of a tendon compensating for an unstable ankle.

Babak Baravarian, DPM, FACFAS, the study’s co-author, emphasizes the importance of inspecting the peroneal tendons during a lateral ankle stabilization procedure to evaluate their integrity as they are often pathological in cases of ankle instability.

“If you are planning a repair of the ligaments, I suggest a magnetic resonance image (MRI) to check the peroneals for tear … If there is no tear on the MRI but the surgeon still suspects a possible tear, a longer incision will allow ligament repair and tendon exploration,” explains Dr. Baravarian, an Assistant Clinical Professor at the UCLA School of Medicine.

Dr. Baravarian notes that MRI is necessary prior to surgery to check tendon, ligament and articular issues. In a case of a peroneal tendon pathology, he recommends repairing the peroneal tendon with a non-absorbable nylon suture and wrapping the tendon with an amniotic membrane to prevent scar formation. Dr. Baravarian notes that he uses a human amniotic membrane (Amniox Medical), which absorbs at three to four months.

When it comes to lateral ankle instability, Dr. Baravarian still advocates initial conservative therapy and only considering surgery when conservative modalities fail to achieve results.

Can A Medical Food Help Alleviate Diabetic Neuropathy Symptoms?

By Brian McCurdy, Senior Editor

A recent randomized trial in the American Journal of Medicine notes that a combination of L-methylfolate, methylcobalamin and pyridoxal-5’-phosphate (Metanx, Pamlab) can improve the symptoms in patients with diabetic neuropathy.

The study focused on 214 patients with diabetic neuropathy, who were randomly assigned to treatment with Metanx or a placebo. The authors found that those taking Metanx reported consistent relief of symptoms, showing improved Neuropathy Total Symptom Scores at week 16 as well as improvement in their quality of life.

Mackie J. Walker Jr., DPM, FACFAS, FASPS, says for the vast majority of patients, Metanx has minimal side effects with significant benefits and improvement in sensory perception and quality of life after three to six months of therapy. He also notes the prescription medical food is less expensive than medications that only provide relief of symptoms of painful diabetic neuropathy.

Dr. Walker prescribes Metanx for every patient with diabetes, cautioning that those with loss of protective sensation most often begin to experience pain after three months of treatment, which is a positive response to treatment. After three months of Metanx use, he will prescribe approved medications such as pregabalin (Lyrica, Pfizer), duloxetine (Cymbalta, Eli Lilly) or gabapentin (Neurontin, Pfizer) to alleviate patients’ symptoms.

“I remind them that Metanx is the only prescription that is addressing the pathophysiology of their disease state. The other medications are only for symptoms,” says Dr. Walker, who practices in the Podiatry Division at Carolina Musculoskeletal Institute in Aiken, S.C.